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Nature of Depression
Seligman (1973) referred to depression as the common cold of psychiatry because of
its frequency of diagnosis. According to BPS figures a staggering 9 million people in
Britain reported feelings of depression to their GP in 1998! However to continue
Seligmans analogy, although this cold may have reached epidemic proportions in the
West it is certainly not pandemic since many cultures and areas of the World report little
or no depression
Characteristics of depression
Depression is an affective disorder in that it is characterized by disturbances of affect (or
mood). During the course of any period of time it is not unusual for a persons mood to
alter. However with affective disorders this variation is more marked and is
accompanied by other symptoms.
These symptoms of depression do vary; the DSM-IV recognize three main types of
depression, only two of which will be mentioned here, and only one of which will be
covered in detail. A possible 6 mark question on the paper could ask you to describe
the symptoms or characteristics of depression. Clearly feeling sad is not going to earn
you very much credit!
Emotional symptoms
The symptoms we most associate with depression, those feelings of sadness, loss of
mood and loss of pleasure from what were previously enjoyable activities. Mood may
also alter during the course of the day, typically being lowest in the morning and
gradually showing improvement as the day progresses. This may be associated with
circadian rhythms.
Physical symptoms
Disturbances of sleep: patients sometimes report insomnia, but sleeping longer than
before is also common, perhaps as patients attempt to escape their problems.
Appetite can also decrease or it may increase in the form of comfort eating. Part of this
may be due to boredom since typically depressed people tend to have lower activity
levels.
Motivational symptoms
Apathy and loss of drive are common. Typically the depressed person will sit around
waiting for things to happen, making no attempt to initiate activity or social contact. This
could be because they dont want people to see them in a depressed state.
Cognitive symptoms
These can vary from negative self-thoughts, loss of self-esteem and self-confidence,
feelings of despair and hopelessness, inability to concentrate on tasks for any length of
time to feelings of inadequacy and blaming themselves for their situation and on
occasions and suicidal thoughts.
PSYCHOLOGICAL EXPLANATIONS OF DEPRESSION
To read up on psychological explanations of depression, refer to pages 441451 of
Eysencks A2 Level Psychology.
Ask yourself
How would the psychodynamic approach explain depression?
How would the behavioural approach explain depression?
How would the cognitive approach explain depression?
What you need to know
PSYCHODYNAMI BEHAVIOURAL
C EXPLANATION APPROACH
Freuds
psychoanaly
tic theory
Evaluation
Research
evidence for
and against
Evaluation
COGNITIVE
EXPLANATIONS
Research
evidence for
and against
Evaluation
LIFE
EVENTS
The
impact
of
stressf
ul life
events
SOCIOCULTURAL
FACTORS
The
influen
ce of
social
and
cultura
l
factors
Psychodynamic Explanation
Freud argued that individuals whose needs werent met during the oral stage of
psychosexual development are vulnerable to developing depression in adulthood
because this causes low self-esteem and excessive dependence.
Individuals whose needs were met to excess during the oral stage are also vulnerable
because they might become too dependent on others. According to Freud, we are
victims of our feelings, as repression and displacement are defence mechanisms in
response to actual loss (death of a loved one) and symbolic loss (loss of status) that
enable us to cope with the emotional turmoil, but can result in depression.
Individuals who are excessively dependent on other people are especially likely to
develop depression after such a loss. Anger at the loss is displaced onto the self, which
affects self-esteem and causes the individual to re-experience loss that occurred in
childhood. Freud believed the superego (or conscience) is dominant in the depressed
person and this explains the excessive guilt experienced by many depressives. In
contrast, the manic phase occurs when the individuals ego, or rational mind, asserts
itself and he/she feels in control.
EVALUATION OF THE PSYCHODYNAMIC EXPLANATION
Has face validity. This approach does have face validity, as, even if a
psychodynamic approach is not favoured, it is widely accepted that childhood
experience can predispose the individual to mental illness in adulthood. For
example, Kendler et al. (1996, see A2 Level Psychology page 442) found adult
female twins who had experienced parental loss through separation in childhood
had an above-average tendency to suffer from depression in adult life.
Early loss does not consistently predict depression. Fewer than 10% of
individuals who experience major losses go on to develop clinical depression.
Freud predicts that the individuals anger is turned inwards on themselves yet
often it is turned outwards on those who are closest instead.
The key weakness of Freuds theory is that it lacks empirical support and
so is neither verifiable nor falsifiable. Furthermore, any link between loss in
childhood and depression is just an association, not causation, and so we cannot
conclude cause and effect.
Behavioural Approach
According to this approach, depression is due to maladaptive learning. The principles of
operant conditioning have been applied to explain depression using reinforcement and
punishment. Depression could be due to a lack of positive reinforcement or too much
punishment.
RESEARCH EVIDENCE FOR THE BEHAVIOURAL APPROACH
Lewinsohn (1974, see A2 Level Psychology page 443) suggests that depression
is due to a reduction in positive reinforcement as a consequence of some form of
loss, e.g. redundancy, relationship breakdown. Also, once depressed, the
individual may receive positive reinforcement such as sympathy and attention.
Learned helplessness occurs when an individual is placed in a no-win
(punishing) situation. When the individual associates a lack of control with a
situation, e.g. when punishment is seen as unavoidable, passive, helpless
behaviour is shown. Seligman (1975, see A2 Level Psychology page 444) tested
his theory by exposing dogs to electric shocks they could not avoid. When they
were then given the opportunity to avoid the shocks by jumping over a barrier the
dogs did not learn to do this, whereas dogs not exposed to unavoidable shocks
readily learned to avoid them. Seligman generalised this to depression in
humans. Stressful experiences may be experienced as unavoidable and
uncontrollable and so result in learned helplessness, which leads to depression.
Hiroto (1974, see A2 Level Psychology page 444) used three groups of human
participants: (1) exposed to a loud noise they couldnt stop; (2) exposed to a loud
noise they could stop by pushing a button; and (3) didnt hear a loud noise. All
participants were then placed in front of a rectangular box with a handle on of it
and exposed to loud noise. Unknown to the participants, the noise could be
switched off by moving the handle from one side to the other. Only the group
previously exposed to a loud noise they couldnt stop showed learned
helplessness by failing to move the handle.
Cognitive Explanations
Cognitive dysfunction in attributional style (Abramson et al.s attribution model) and view
of self, the world, and the future (Becks cognitive triad) have been linked to the
development of depression. Negative schemas develop during childhood as a
consequence of critical interpersonal experiences, and are activated when the individual
experiences similar situations in later life.
RESEARCH EVIDENCE FOR COGNITIVE EXPLANATIONS
Abramson, Seligman, and Teasdale (1978, see A2 Level Psychology page 445)
developed Seligmans work with the attribution model, which considers how
people respond to failure. Individuals susceptible to depression attribute failure to
internal (my own fault), stable (things will never change), and global (applies the
failure to a wide range of situations, e.g. Im rubbish at everything) causes.
Such thinking is more negative and self-critical than attributing experience to
external, unstable, and specific causes. This suggests that aversive stimuli on its
own doesnt cause learned helplessness and depression, as this is dependent on
how the individual thinks. Hence, the attribution model supports the role of
cognitive factors and improves on the original learned helplessness theory.
Abramson, Metalsky, and Alloy (1989, see A2 Level Psychology page 445)
developed the original theory because they attached less importance to specific
attributions and more importance to the notion that depressed individuals
develop a general sense of hopelessness.
Beck and Clark (1988, see A2 Level Psychology page 446) proposed the
cognitive triad, which is the individuals thoughts about self, world, and future.
The more negative and therefore the more hopeless the cognition, the greater
the risk of depression. Beck also identified errors in logic or cognitive biases,
such as magnification, minimisation, and personalisation, where weaknesses are
exaggerated and strengths under-emphasised. Polarised thinking is another bias,
which is also known as black-and-white thinking. For example, depressives often
set themselves unattainable standards such as, I must be liked by everybody; if
not Im unlovable.
A prospective study by Lewinsohn, Joiner, and Rohde (2001, see A2 Level
Psychology page 446) measured negative or dysfunctional attitudes in
participants who did not have a major depressive disorder at the outset of the
study. They re-assessed the participants 1 year later and found those high in
dysfunctional attitudes were more likely to develop major depression in response
to negative life events. This supports faulty cognition as a cause rather than an
effect of depression.
Evans et al. (2005, see A2 Level Psychology pages 446447) also conducted a
prospective study and found that women with the highest scores for negative
self-beliefs during pregnancy were 60% more likely to become depressed
subsequently than those with the lowest scores.
However, as you may remember from studying stress at AS, we are only as stressed as
we think ourselves to be. Thus, the critical mediating factor may be self-perception,
which suggests that cognitive factors predispose the individual to depression more than
the life events themselves as it is the way we think about them that is crucial. This partly
accounts for why people can experience very similar stressful situations and some
become depressed whereas others dont.
However, to account fully for such variation the interaction of biological predisposing
factors (innate physiological reactivity) and environmental factors (stress) needs to be
considered. Further limitations of the life events research include the fact that the
information is obtained retrospectively several months afterwards, and so there might
be problems remembering clearly what happened. Cause and effect is an issue
because it is unclear whether life events have caused depression or depression caused
the life events. For example, marital separation might cause depression, but depression
can play an important role in causing marital separation.
Socio-cultural Factors
According to socio-cultural theorists (e.g. Nolen-Hoeksema, 1990, see A2 Level
Psychology page 448), the incidence of major depressive disorder is influenced strongly
by social and cultural factors. An example of a social factor is the presence of an
intimate friend because this has been found to reduce incidence of depression (Brown &
Harris, 1978, see A2 Level Psychology page 448).
Marital status is another important social factor. Blazer et al. (1994, see A2 Level
Psychology page 448) found that divorced individuals were more depressed than
individuals who were married or who had never been married. However, we cannot be
sure of the direction of effect, i.e. if divorce triggered depression or if depression led to
divorce.
Culture has an effect on the nature of the symptoms reported because individuals in
non-Western countries report mostly physical symptoms (e.g. fatigue, sleep
disturbances), whereas guilt and self-blame are more common symptoms in Western
countries.
A sub-cultural factor is evident in the fact that major depression is twice as common in
women in most countries of the world (Hammen, 1997, see A2 Level Psychology page
448). Note you could consider this as an issue of bias in terms of diagnosis as it may be
women are just more likely than men to be diagnosed with depression. However, the
arguments against this are many as maybe women are more likely than men to report
their emotional problems. Or maybe women have more reasons than men to be
depressed, given that they are exposed to more stressors than men are, e.g. gender
bias in the workplace, the triple burden of work, home, and child care, and the fact they
are often poorer than men.
Kendler et al. (1993, see A2 Level Psychology page 449) found that women reported
significantly more negative life events than men in the past year. It is also possible that
women rely on a more emotion-focused approach and so spend a lot of time thinking
about their problems and focus excessively on their emotions. Whereas men are more
problem-focused, or if they do take an emotion-focused approach they seek distraction
from their problems (e.g. drinking alcohol) (Nolen-Hoeksema, 1991, see A2 Level
Psychology page 449).
So what does this mean?
Now that we have covered psychological factors, it is no doubt clear there are
numerous possible contributing factors to depression, which of course makes it all the
more difficult to explain the disorder.
The diathesisstress model offers a more comprehensive account because it considers
the interaction of nature and nurture. This better accounts for individual differences,
particularly in those who share genes in common, such as identical twins where one
develops depression and the other doesnt. The diathesisstress model can explain this
because, whilst both twins will have inherited the genetic component, they may
experience different interactions within the family or stressful life events. Consequently,
the predisposition may be triggered in one twin but not the other.
Genetic predispositions may interact with the psychological explanations as faulty
cognitions and negative family interactions may be linked to genetics. Thus, a multidimensional approach is essential as multiple factors interact to explain the disorder. It
is also worth noting that an idiographic (individually-specific) rather than a nomothetic
(universal) approach is needed as the factors will interact in different ways for different
cases of depression.
Psychological Treatments for Depression
Cognitive Behaviour Therapy (CBT)
CBT is currently seen as being the most effective psychological method of treating
depression. Originally devised by Aaron T. Beck it combines primarily the cognitive
model with aspects of psychoanalysis and behaviour therapy.
The basic aim of CBT is cognitive restructuring designed to bring about lasting
changes in target emotions and behaviour (Wessler 1986). To this end the therapist
and the patient (from here on in referred to as the client) form a relationship in which
the irrational and overly negative beliefs of the client are recognized and challenged by
the therapist.
CBT has been widely used by many therapists for many years. During that time it has
undergone many revisions with each therapist tailoring the procedure to their own
needs. As a result there are many forms of CBT in use. However, they all have various
characteristics in common and Beck and Weishaar (1989) suggest the following five
common elements:
Patients are taught to:
1. Monitor their negative and automatic cognitions
2. Recognise the link between cognitions, affect (mood) and behaviour
3. Consider evidence for and against these automatic thoughts
4. Replace biased thoughts with more realistic ones
5. Learn to identify and then change the beliefs that predispose the client to
distorted thinking.
Making the client aware of the way cognitive and behavioural aspects feed into mood is
referred to as the educational phase.
Thought catching (cognitive element)
Considers the link between irrational thinking and low mood. Typically the therapist will
set homework in which the client is set clear and achievable goals such as talking to a
member of the opposite sex or a stranger or perhaps recognising their automatic
thoughts and challenging these. Homework extends the therapy into everyday life.
However, the therapist needs to be certain that the homework set is realistic. Setting a
task that cannot be achieved is likely to reinforce the clients negative thinking still
further.
Behavioural activation (behaviourist element)
The client is encouraged to take part in enjoyable activities. It is common for patients
with depression to cut themselves off and stop socialising. Here the therapist
encourages the client to get out and engage in activities that they enjoyed before the
depression. For example, play sports, go to the cinema, socialise with friends..
Exercise is seen as being particularly beneficial:
Babyak et al (2006) randomly allocated 156 depressed patients into one of three
groups:
1. Four months of aerobic exercise
2. Drug treatment
3. Combination of exercise and drug treatment
After the four months all showed significant improvement. Six months later when the
patients were revisited the groups taking exercise had a significantly lower level of
relapse.
With CBT there are usually about 20 sessions followed by boosters in the first year to
help prevent relapse.
Does CBT work?
An early study by Rush et al (1977) showed CBT to be more effective in reducing low
mood than the drug imimprimine (a tricyclic). However, in this particular study the most
striking feature was the lack of success of the drug!
Elkin (1994) made a similar comparison and found that both CBT and imiprimine
resulted in almost complete removal of depressed symptoms in 55% of patients. Both
were significantly better than placebo, but the drug did work faster.
Hollon et al (2005)
This will sound familiar because weve looked at it as evidence for the effectiveness of
drugs, but here it is again. Depressed patients were treated for 16 weeks. They
received either:
An SSRI (paroxetine) or Cognitive therapy
Similar numbers of each group (about 60%) showed considerable improvement. These
successes were then followed up for a further 12 months. See above for further details
and results.
What this tells us
When CBT was stopped and no further treatment was received, relatively few suffered
relapse into depression. This suggests that cognitive therapy has dealt with
the cause of the depression.
When drug therapy is given and maintained relapse rate is relatively low (though not as
low as therapy) which suggests the drugs are working provided they are maintained.
The most telling figure however, is the 76% that relapse when the drugs are withdrawn.
This confirms that drugs are fine until medication stops. During the prescribed period
the drugs are reducing the symptoms but not dealing with the causes. If they were then
the patient would be fine when medication stopped. In fact three quarters of patients
become depressed again. Drugs appear to be palliative. This suggests that CBT is to
be preferred to drugs.
Further evidence for the curative nature of CBT was produced by Segal et al (2005).
Groups of patients were treated with either CBT or drugs. As with the Hollon study, both
that has become distorted. For example grief that lacks sadness but manifests itself in
non-emotional ways such as odd behaviours.
Aim of PIT: to facilitate mourning
2. Role disputes
When there are differing expectations about the nature or outcome of a relationship
between the people involved. Perhaps one wanting it to become more serious when
the other doesnt.
Aim of PIT; to recognise the nature of the dispute and decide a plan of action that will
resolve the misunderstanding.
3. Role transitions
Depression caused by an inability to cope with life changes and events. Typical
examples would include divorce, retirement, leaving home. The depressed person is far
more likely to see these as a loss rather than an opportunity.
Aim of PIT: Get the patient to give up the old role and accompanying sadness, guilt or
anger
4. Interpersonal deficits
The patient has too few or total lack of supportive relationships, for example no intimate
relationships resulting in feelings of inadequacy and low self-esteem.
Aim of PIT: to reduce social isolation. In this case PIT is more likely to focus on past
relationships.
Does PIT work?
Paley et al (2008) concluded that PIT is as effective as CBT.
They followed 62 patients over a 52 month period. The effectiveness of the PIT was
measured using the BDI (Beck Depression Inventory). 34% of patients showed
significant reduction in depressed symptoms.
However, this study was poorly controlled (by the authors own admission) so it is
difficult to be certain that it was just the PIT bringing about the improvements.
Brief interventions can also be useful. 54 NHS patients were either given 12 weeks of
PIT or placed on a waiting list for treatment (control group).
In the 33 patients that completed the study there were significant improvements.
However, there was a very high drop out rate, mostly from the ones on the waiting list.
Overall evaluation
Many psychologists consider CBT to be too limited in its approach, considering mostly
the cognitive processes underlying the negative cognitions. PIT recognises the
importance of relationships in the development and treatment of depression so adds a
new dimension to therapy.
PIT is especially useful in depression known to be at least partly due to relationship
issues, such as divorce and bereavement.